Inversion Test and Sitting-Up Oculomotor Patterns in Patients with Graviceptive Heavy Posterior Cupula - A Case Series.

A graviceptive heavy posterior cupula typically results from cupulolithiasis and clinically manifests as short vertigo spells when the head moves in the provocative position. Half-Hallpike test (HHT) in posterior cupulolithiasis (PSC-BPPV-cu) elicits an upbeating ipsitorsional nystagmus (UBITN), which lasts more than a minute as per the consensus criteria developed by the Barany Society. In the last decade, cases with canalolithiasis in the short arm of the posterior semicircular canal (PSC-BPPV-sa), wherein the otoconial debris falls on the utricular side of the posterior cupula on getting up from supine, rendering it heavy (graviceptive), have been reported. Such patients complain of sitting-up vertigo, associated with a constant disequilibrium, and anteroposterior truncal oscillations are recorded by ad hoc posturography in many of these patients. The oculomotor patterns generated in such patients during the HHT may be identical to those resulting from PSC-BPPV-cu. Rarely do the two conditions (PSC-BPPV-cu and PSC-BPPV-sa) coexist. Nine cases of graviceptive heavy cupula were diagnosed at our center over a period of 6 months from September 1, 2022, to March 31, 2023, with their characteristic diagnostic oculomotor patterns, distinguishing features, and management discussed. We propose a grading system for the inversion test during the HHT that reliably distinguishes PSC-BPPV-cu from PSC-BPPV-sa, as well as when the two conditions coexist.

Vestibular Rehabilitation of the Persons affected by Benign Paroxysmal Positional Vertigo (BPPV) by Physical Therapy and Repositioning Maneuvers.

Vestibular rehabilitation therapy (VRT) mainly comprises physical therapies that encourage head, eye, and truncal movements, accelerating the recovery of patients with acute peripheral labyrinthine dysfunction. VRT aims to improve vestibular hypofunction by reinforcing vestibulo-ocular, vestibulospinal, and vestibulocollic reflexes. An asymmetry in peripheral vestibular inputs from the pair of membranous labyrinths to the central nervous system frequently results from vestibular lithiasis, causing benign paroxysmal positional vertigo (BPPV). The article discusses the pathophysiology, subtypes, and diagnostic oculomotor patterns generated during positional tests in each subtype of BPPV. Accurate identification of the pathophysiology (canalolithiasis versus cupulolithiasis) as well as the involved semicircular canal (localization and lateralization) is crucial for the unerring VRT of BPPV by physical therapies and/or repositioning maneuvers. The article elaborates the currently known variants of BPPV, the anatomico-physiological correlation between otoconial location and oculomotor patterns generated during the diagnostic positional tests in terms of the direction, latency, and duration of the elicited positional nystagmus [Figures 1 and 2; Table 2]. A detailed description of the treatment of different BPPV subtypes with repositioning maneuvers and/or physical therapy is given [Figures 3-8; Table 3].

A case of apogeotropic horizontal canal benign paroxysmal positional vertigo that transformed to the geotropic variant during treatment with Appiani maneuver, followed by successful treatment with Gufoni maneuver.

Lesions at three possible sites can masquerade as apogeotropic horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV), namely: 1) short anterior (ampullary) arm canalolithiasis; and 2) culpulolithiasis, which may be either canal (Cup-C) or utricle-sided (Cup-U). There are no clinical methods or investigations to determine the exact pathological site when a patient with a history compatible with HSC-BPPV is found to have apogeotropic positional nystagmus on the supine roll test. Therefore, the treatment of apogeotropic variant of HSC-BPPV not only poses difficulties but the therapeutic options need to be tailored according to the ostensible localization of the pathology. If the apogeotropic HSC-BPPV is transformed into the geotropic variant, it becomes relatively easier to treat, as the treatment options for the latter are very well established. There are reports of cases of the apogeotropic variant of HSC-BPPV being transformed inadvertently during diagnostic positional tests as well as during therapeutic (intention-to-treat) positional maneuvers. I report here a case of an apogeotropic variant of right HSC-BPPV, that transformed into a geotropic variant during the therapeutic (intention-to-treat) Appiani maneuver, which was subsequently successfully treated with two sequences of Gufoni maneuver after transformation. The patient was followed up at one and 24 hours after the second sequence of Gufoni maneuver with a diagnostic supine roll test, which was negative. The case report is supported by seven videos of the diagnostic and therapeutic positional maneuvers revealing positional nystagmus, its appearance, change, and disappearance as clinical events unfolded during the examination and treatment.